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Cavotricuspid Isthmus Mapping to Assess Bidirectional Block

During Common Atrial Flutter Radiofrequency Ablation

Jian Chen, MD; Christian de Chillou, MD; Tarek Basiouny, MD; Nicolas Sadoul, MD;
Jorge Da Silva Filho, MD; Isabelle Magnin-Poull, MD; Marc Messier, PhD; Etienne Aliot, MD

BackgroundWe sought to compare published methods to an alternative approach ascertaining cavotricuspid isthmus
(CTI) block during atrial flutter ablation.
Methods and ResultsIn 39 consecutive patients who underwent an atrial flutter ablation procedure, a 24-pole mapping
catheter was positioned so that 2 adjacent dipoles were bracketing the targeted CTI line of block (LOB), with proximal
dipoles lateral to the LOB and distal dipoles in the coronary sinus. Two pacing sites were lateral (positions A and B)
and 2 were septal (positions C and D) to the LOB, with locations A and D closest to the LOB. A resulting CTI block
was accepted when 3 criteria were fulfilled: (1) complete reversal of the right atrial depolarization on the 24-pole
catheter when pacing in the coronary sinus, (2) conduction delays from A to D greater than from B to D, and
(3) conduction delays from D to A greater than from C to A. A successful CTI block was obtained in all patients. Before
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CTI block was obtained, a progressive CTI conduction delay was observed in 11 patients (28.2%). During the procedure,
the 3 criteria defined above were either all present or all absent.
ConclusionsThis study establishes that reversal of the atrial depolarization sequence up to the LOB is a definitive and
mandatory criteria of successful atrial flutter ablation. (Circulation. 1999;100:2507-2513.)
Key Words: atrial flutter n catheter ablation n arrhythmia

R adiofrequency (RF) ablation is widely used17 to cure

symptomatic patients with common atrial flutter (AF).
Some authors even propose that RF ablation could be used as
1997 and June 1998 for RF catheter ablation of a common drug
resistant AF (negative sawtooth flutter waves in leads II, III, and VF
with an isoelectric positive pattern in V1). Nineteen patients (48.7%)
also presented nonpredominant episodes of paroxysmal atrial fibril-
a first line treatment in this clinical setting.7 lation. Thirteen patients (33.3%) had a structural heart disease,
The cavotricuspid isthmus (CTI), lying between the infe- including coronary heart disease (n54), operated valvular heart
rior vena cava (IVC) and the tricuspid annulus, is the disease (n53), hypertensive cardiomyopathy (n54), and congenital
common target of AF ablation.6 16 Recent studies have shown atrial septal defect (n52). Before the ablation procedure, 3 additional
patients were equipped with a pacemaker either for sick sinus
that a resulting bidirectional conduction block in the CTI syndrome (n51) or for an atrioventricular block (n52). A patient
should be the end point of the ablation procedure.8 13 informed consent was obtained from all patients before the ablation
The method most widely used to assess this complete CTI procedure.
block is based on the depolarization sequence observed in the
right atrial lateral wall as well as the activation times Catheter Positioning
measured on His bundle recordings and in the coronary sinus A 24-pole mapping catheter (Orbiter, Bard Inc, 2-7-2 mm elec-
trode spacing) was positioned via the femoral vein in the CS, then
(CS) region. These are assessed using different pacing advanced and rotated so that the distal poles were in the CS and the
sites.8 10 Another technique13 relies on double potentials proximal poles positioned around the tricuspid annulus, assessed by
mapping within the CTI. a 45 left anterior oblique and 30 right anterior oblique projection
The aim of this study was to evaluate the accuracy of (Figure 1). Usually 4 to 5 pair of electrodes were inside the CS, 4 to
bracketing the targeted line of block (LOB) using a single 5 pair on the CTI and 2 to 4 pair on the lateral atrial wall. With the
Orbiter catheter in this position, there were always 2 adjacent pair of
24-pole catheter to assess bidirectional CTI conduction block electrodes bracketing the RF ablation line created within the CTI.
during RF ablation of AF. During the procedure, the position of this catheter was repeatedly
checked under fluoroscopic control. The tendency to shifting from
Methods the lateral right atrial wall toward a more posterior position (ie,
closer to the crista terminalis) was corrected with a straightforward
Study Population twist and repositioned.
The study population consists of 39 consecutive symptomatic pa- A deflectable 7F quadripolar catheter (Cordis Webster, Johnson &
tients (34 men, mean age 60611 years) admitted between December Johnson Inc, 2-mm electrode spacing, 4-mm tip electrode) or a

Received April 19, 1999; revision received July 19, 1999; accepted August 4, 1999.
From the Service de Cardiologie, Hopital Central, Nancy, France.
Correspondence to Christian de Chillou, MD, Service de Cardiologie, Hopital Central, 29 Av du Marechal de Lattre, 54000 Nancy, France. E-mail
1999 American Heart Association, Inc.
Circulation is available at

2508 Circulation December 21/28, 1999
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Figure 1. Fluoroscopic views of atrial flutter ablation. Left, 30 right anterior oblique projection; right, 45 left anterior oblique projec-
tion. Orb indicates Orbiter catheter; RF, radiofrequency ablation catheter; HIS, catheter recording the His bundle electrogram; and CS
OS, coronary sinus ostium.

deflectable 8F quadripolar catheter (EP technologies, Boston Scien- The CTI conduction was evaluated in sinus rhythm postablation
tific Inc, 2.5-mm electrode spacing, 8- or 10-mm tip electrode) were and in sinus rhythm either preablation or when patients in AF were
used for the CTI mapping and ablation. In addition, a quadripolar converted to sinus rhythm periablation. This was performed sequen-
catheter (Daig, St Jude Medical Inc, 10-mm electrode spacing) was tially with a 4-pacingsite protocol (Figure 2): bipolar pacing at sites
used to record and pace in the His bundle region. A or B or D then at site C (His bundle). Sites A and B are defined
on the lateral side of the LOB and sites C and D on its septal side.
Electrophysiological Study and Ablation Procedure Site A is 1 of the 2 dipoles immediately adjacent and lateral to the
Endocardial bipolar electrograms were filtered between 30 to 500Hz targeted LOB; site B is 1 of the 2 dipoles immediately adjacent and
and recorded on a Midas 8200 system (Marquette Medical Systems lateral to site A; site D is 1 of the 2 dipoles immediately adjacent and
Inc) and analyzed at a chart speed of 100 mm/s. Electrical stimula- septal to the targeted LOB.
tion was delivered through an external stimulator (Biotronik UHS
20, Biotronik Inc) with a 2-ms pulse width at twice the diastolic Definition of Complete Bidirectional CTI
threshold. Ablation was performed with the Stockert-Cordis RF Conduction Block
generator and energy was applied in a temperature-controlled mode A complete bidirectional CTI block fulfilled the following criteria:
with a 60C to 70C target. (1) a descending wave front on the lateral atrial wall during CS
The ablation generated a line of RF lesions in the CTI using a pacing representative of a reversed atrial depolarization sequence,
technique described by other authors2,5,6 and resumed here. The (2) a greater activation delay at site D when pacing at site A was
ablation catheter was positioned on the ventricular side of the CTI compared with pacing at site B (AD delay.BD delay), and (3) a
and progressively dragged (3- to 4-mm steps) to the IVC under greater activation delay at site A when pacing at site D was compared
fluoroscopic control. At each new position of the ablation catheter, with pacing at site C (DA delay.CA delay).
RF energy was delivered for 1 minute. An unsuccessful bidirectional
block after reaching the IVC position would sponsor a renewed
attempt along the same line, with the difference that RF current be
delivered only at sites were no atrial double potentials could be
Ablation was performed with patients either in AF or in sinus
rhythm. When in sinus rhythm, the ablation was performed with
pacing at 600 ms in the CS and continuous atrial activation recording
along the Orbiter catheter. Patients in AF obtained a straight ablation
line by delivering the RF energy when the local atrial electrogram
occurred within 5 ms of the middle of the plateau phase preceding
the F wave. For ablation procedures performed under CS pacing, the
electrophysiological mark became a fixed interval (65 ms) between
the pacing spike and the local electrogram recorded on the ablation
The bidirectional conduction block within the CTI defines the end
point of the ablation procedure. Thirty minutes after the bidirectional
block was obtained, all patients underwent a postablation control. A
recurring conduction reinitiated the ablation procedure until a com- Figure 2. Schema of the right atrium, as seen from the 45 LAO
plete bidirectional block was obtained again and reconfirmed after projection, showing the 4 stimulation sites in relation with the
another 30-minute wait. anatomical structures.
Chen et al Atrial Flutter Ablation 2509

Figure 3. Atrial flutter termination during

RF energy application after depolariza-
tion of dipole 11-12. The ablation cathe-
ter is positioned between dipoles 11-12
and 9-10. Progressive fractionation of
the atrial electrogram signal occurs on
dipole 11-12 (1st to 3rd beat) with an
increase in the conduction delay (3rd
beat) between dipoles 11-12 and 9-10
before flutter termination.

Definition of Undirectional Conduction Block patients requiring further RF applications to obtain a CTI
Within the CTI block. In group B patients, the dipole just lateral to the
A clockwise (mediolateral17 ) conduction block fulfilled the follow- targeted LOB was the last one to depolarize on interruption of
ing criteria: 1) AD delay,BD delay, and 2) DA delay.CA delay. AF (Figure 3). Sinus rhythm resumed after a mean number of
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A counterclockwise (lateromedial17 ) conduction block fulfilled 967 RF applications (ranging from 1 to 28). From a topo-
the following criteria: 1) AD delay.BD delay, and 2) DA
delay,CA delay. logical perspective, sinus rhythm was obtained on the first
pass approximately midway between the ventricular starting
Follow-Up point and the IVC in 5 patients (33.3%), whereas 4 patients
Patients were monitored for 48 hours postablation, then discharged. (26.7%) were resolved near the last quarter, closer to the IVC.
No antiarrhythmic drug therapy was prescribed except for some Six patients (40%) required numerous attempts at various
patients with history of atrial fibrillation. The patients were followed locations.
on an outpatient basis with clinical evaluations and 24-hour Holter
recordings performed at 2, 4, 6, 9, and 12 months after
Episodes of AF reoccurred spontaneously in 5 group B
hospital discharge. patients before CTI block was obtained. Transient AF were
Long-term clinical validation of the ablation procedure follows observed during the procedure in another 4 (group A) patients
absence of recurring AF. Documented recurrences of AF promoted a before CTI block achievement.
second electrophysiological study of the CTI conduction and led to Complete CTI block was successfully achieved in 1 ses-
a repeated ablation procedure. Undocumented events, however, first
sion in all patients. Mean number of RF application was
required proof of AF inducibility before a renewed ablation could be
attempted. 17611 (ranging from 4 to 48). Mean total procedure duration
(from femoral puncture to catheter withdrawal) was 168671
Statistical Analysis minutes (ranging from 60 to 300), and mean fluoroscopic
Continuous variables are expressed as mean6SD and compared time was 46622 minutes (ranging from 11 to 76).
using the unpaired Students t test. P,0.05 was considered statisti- The ablation procedure required continued CS pacing in all
cally significant. except 1 patient (in whom complete bidirectional CTI block
was observed when sinus rhythm was restored). The first
Results block evidenced was mediolateral because the CS was paced.
Catheter Positioning This was always associated with a lateromedial conduction
The Orbiter catheter was positioned as described earlier in 36 block; a unidirectional conduction block in the CTI was never
of 39 patients (92.3%). During the procedure, the catheter observed here. Because mediolateral conduction within the
shifted in 2 of these 36 patients (5.6%), this required a CTI was continuously monitored during energy delivery, the
straightforward repositioning. The ideal catheter position was block was always demonstrably abrupt, with the change in
unreachable in 3 patients due to our 1) inability to catheterize the activation sequence on the Orbiter catheter appearing
the CS in 2 patients (both with an atrial septal defect), and 2) from one beat to the next (Figure 4).
very unstable position of the catheter in 1 patient. In these 3 During the 30-minute postablation period, CTI conduction
patients, the Orbiter catheter was positioned so that the distal resumed once in 10 patients (25.6%) and twice in 3 patients
dipole was applied just outside the CS ostium. This position (7.7%). The conduction recurrence delay ranged from 5
was unstable, requiring several catheter repositioning during seconds to 25 minutes. A final CTI block could be success-
the procedure. fully created in all cases after 1 to 6 additional RF energy
Ablation Procedure
At procedure onset, 24 patients (61.5%, group A) were in Electrophysiological Data
sinus rhythm whereas the remaining 15 patients (38.5%, During CS atrial pacing, a progression in conduction delays
group B) presented with AF. In group B patients, a restored within the CTI evolved until a complete block occurred, the
sinus rhythm during RF energy applications was associated collision of the clockwise and counterclockwise wave fronts
with a complete CTI block in only 1 patient, the remaining 14 thus shifting to various positions in the isthmus (Figure 5).
2510 Circulation December 21/28, 1999

Figure 4. Abrupt change with complete

reversal of depolarization sequence on
the Orbiter catheter (2nd to 3rd beat)
during RF energy application.

The distance separating the target LOB and the evolving the activation delays were first measured when sinus rhythm
atrial collision zones could be measured with the help of the resumed and were significantly longer than preablation de-
Orbiter catheter. In 28 patients (71.8%), the site of collision lays measured in group A. No significant differences in
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of the 2 wave fronts was always .44 mm away from the activation delays were observed between group A and group
target LOB. The maximum shift, however, was found at a B patients when the CTI conduction block was obtained. In
distance of 11 mm (2 electrode pairs) away from the target group A patients, the mean increase in the activation delays
LOB in 4 patients, 22 mm away (3 electrode pairs) in 5 were 147.3626.4 ms (ranging from 118 to 202 ms) for AD,
patients, and at 33 mm (4 electrode pairs) in 2 patients. For 105.6625.4 ms (ranging from 75 to 180 ms) for BD,
these 11 patients, proximity of the shifted collisions zones 152.6625.5 ms (ranging from 119 to 203 ms) for DA, and
with the target LOB could suggest (erroneously) a CTI block 107.1623.9 ms (ranging from 78 to 160 ms) for CA. Figure
had the distal pole of the mapping catheter been positioned 6 shows these different activation delays after CTI conduc-
11, 22, or 33 mm lateral to the target LOB. This would have tion block is obtained.
wrongly stopped the procedure if the reversal depolarization During CS pacing, a complete reversal of the atrial depo-
criteria alone had been used with a catheter mapping the larization was always associated with the AD delay longer
infero-lateral right atrial wall only, missing 4 (10.2%), 9 than the BD delay (178.0630.7 versus 153.8627.7 ms,
(23.1%), and 11 (28.2%) patients, respectively, with the distal P,0.001) and with the DA delay longer than the CA delay
dipole positioned 11, 22, and 33 mm lateral to the LOB. (181.1627.1 versus 156.1625.5 ms, P,0.001). When only a
The Table shows the changes in the different activation partial reversal of the atrial depolarization was observed, the
delays measured before the ablation procedure and after a AD delay was constantly shorter than the BD delay
complete conduction block was obtained. In group B patients, (106.6623.3 versus 133.8620.9 ms, P,0.001 [values for

Figure 5. Shift in the collision of the clockwise

and counterclockwise wave fronts during coro-
nary sinus pacing during the ablation proce-
dure. A, collision at dipole 17-18 (lateral right
atrium) at baseline. B, collision at dipole 11-12
after 9 RF pulses. C, collision at dipole 9-10
after 11 RF pulses. D, complete reversal of
depolarization sequence on the Orbiter cathe-
ter after 15 RF pulses.
Chen et al Atrial Flutter Ablation 2511

Activation Delays Recorded Before the Ablation Procedure (Group A Patients) or

at Sinus Rhythm Resumption (Group B Patients), and After Complete CTI
Conduction Block was Obtained
Activation Delays A to D B to D D to A C to A
Group A patients (n524)
Before ablation 28.5611.5 49.6617.6 26.9610.9 49.4613.0
Range (1548) (2885) (1544) (3575)
After successful ablation 172.7626.5 148.3624.5 177.8624.1 153.8624.2
Range (138220) (105210) (140223) (115195)
Group B patients (n515)
At sinus rhythm resumption* 40.3616.3 62.5619.6 42.3618.0 64.6618.6
Range (2568) (42105) (2068) (4395)
After successful ablation 185.5634.7 161.6630.1 185.1630.7 158.9627.2
Range (122245) (118220) (143242) (115205)
A, B, C, and D sites are defined in Methods and presented in Figure 2.
*Data from 14 of 15 patients (no data available for patient with CTI block at sinus rhythm
resumption). All numbers are expressed in ms. P,0.01, and P,0.05 compared to the preablation
data from group A patients. No statistical difference compared to the postablation data from group
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A patients.

maximal shift in collision wave fronts]) and the DA delay At a mean follow-up of 10.462.0 months (range 7.5 to
was always shorter than the CA delay (109.7621.2 versus 14.5), 2 of 39 patients (5.1%) experienced at least 1 symp-
139.3620.9 ms, P,0.001 [values for maximal shift in tomatic episode of AF, starting 3 and 8 weeks after hospital
collision wave fronts]). discharge. In these 2 patients (one being treated with flecan-
ide and the other receiving no antiarrhythmic drug), a control
Follow-Up electrophysiological study showed a return to CTI conduction
No significant complications occurred during the ablation
associated with the recurrence of the arrhythmia. Using the
procedure and none occurred during the hospital stay. Thirty-
same protocol as described above, a second ablation proce-
one patients received no antiarrhythmic therapy during the
hospital stay and during the follow-up period. Eight patients dure was successfully performed in these 2 patients.
with a previous history of paroxysmal atrial fibrillation were In addition, 7 other patients underwent a control electro-
discharged with an antiarrhythmic drug treatment; 5 patients physiological study 4 to 8 months after the ablation proce-
on flecanide (200 mg daily), and 3 patients on cibenzoline dure. This was performed in the setting of an atrial fibrillation
(260 mg daily). An additional 6 patients were discharged with ablation procedure in 2 patients or because of undocumented
b-blocker therapy for coronary artery disease (3 patients) or recurrent palpitations in 5 patients. In all 7 patients the control
hypertension (3 patients). electrophysiological study showed a persistent CTI conduc-

Figure 6. Endocavitary activation

sequences on the Orbiter catheter when
pacing at site A, B, C, and D after a
complete cavotricuspid isthmus conduc-
tion block was obtained (AD.BD and
DA.CA). Note that AD and DA delays
are similar.
2512 Circulation December 21/28, 1999

tion block and noninducibility of AF either with a pro- be longer than the BD delay despite the persistence of a
grammed atrial stimulation (from 1 to 3 atrial extrastimuli mediolateral cavotricuspid conduction. A similar situation is
during sinus rhythm, and with atrial pacing at 600 and 400 ms also conceivable with mediolateral conduction. The following
cycle length) nor using atrial burst pacing (from 400 to 200 observations, however, marshal against this limitation: 1) the
ms in 10-ms decrements). complete reversal in activation sequence on the Orbiter
catheter was always abrupt, this being more consistent with
Discussion the appearance of a conduction block rather than a slow
This study investigates the accuracy of a technique based on conduction; 2) complete reversal of the depolarization se-
bracketing the targeted LOB to assess a bidirectional conduc- quence was always associated with the other 2 criteria used to
tion block within the CTI during RF catheter ablation of AF. define complete cavotricuspid conduction block and; 3) when
Four conclusions can be drawn from this work: 1) this CTI conduction resumed, all phenomena defining a complete
technique is feasible in the majority of patients (92.3%), with cavotricuspid conduction block disappeared simultaneously.
a need to reposition the catheter during the procedure in only This regular, simultaneous, all or none situation of all 3
5.6% of the patients; 2) to achieve a complete mediolateral criteria supports a different atrial depolarization process on
cavotricuspid block, reversal of the atrial depolarization the lateral side of the targeted LOB when a complete reversed
sequence during CS pacing has to be complete, with the wave depolarization is observed. This is further supported by the
front descending from the lateral atrial wall to the dipole observation that the control electrophysiological study of the
immediately adjacent (within a few millimeters) to the 2 patients who experienced AF during the follow-up fulfilled
targeted LOB; 3) complete reversal of the atrial depolariza- none of the criteria defining a complete cavotricuspid con-
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tion sequence obtained on the Orbiter catheter during CS duction block.

pacing is an essential and sufficient condition to conclude The literature reports unidirectional and/or rate-dependent
bidirectional CTI block, because multiple-site pacing (A, B, conduction blocks within the CTI in up to 31% of patients
C, and D) and measured activation delays always coincide after CTI ablation.9,11 This has not been evidenced in our
with this condition, given that unidirectional block was never series nor in Potys report.8 There is no clear explanation
observed; 4) multiple-site atrial pacing with activation delay regarding these discrepancies. Because unidirectional block is
measurements may be used as an alternative end point to the basis of reentry phenomenon, one would expect that the
assess complete cavotricuspid conduction blocks: this is last atrial paced beat in any atrial burst induces at least one
useful as multiple-site atrial pacing can be performed without reentrant atrial beat. Hence, in case of a lateromedial cavotri-
need of a multipolar catheter. cuspid block, the last atrial paced beat when pacing at site A
This technique allows a permanent monitoring of the CTI would depolarize successively sites B, C, D, then site A and
conduction, enabling real-time evaluation of mediolateral B because of slow or normal mediolateral cavotricuspid
CTI conduction. Our procedure includes a 30-minute obser- conduction. To our knowledge, such a phenomenon has never
vation period that is often not mentioned in literature reports been described. This supports the hypothesis that activation
but seems of significance, as up to 33.3% of our population patterns that have been described as unidirectional block
exhibited periprocedural cavotricuspid conduction recur- more probably correspond to a slow, bidirectional conduction
rence, some up to 25 minutes after an apparently successful within the CTI.
The proof of a bidirectional conduction block within the Limitations
CTI remains a critical issue in the confirmation of an ablated The ability to induce AF was not evaluated during the
AF. While pacing in the CS, reversal of the atrial depolar- ablation procedure because recent studies8,10 12 have shown
ization sequence on the Orbiter catheter had to be docu- that complete bidirectional conduction block in the CTI is, by
mented up to the targeted LOB to eliminate residual medio- far, the best marker for long-term success after RF ablation of
lateral conduction. Despite which, a very slow mediolateral AF. No systematic electrophysiological control was war-
conduction may still persist within the CTI, which explains ranted, thus information on the persistence of the cavotricus-
the additional criteria defining a complete cavotricuspid pid block is unavailable in the entire study population.
conduction block. When there is no mediolateral block, The 600 ms CS pacing cycle length is about 3 times longer
pacing at site D will lead to an earlier depolarization of site A than AF cycle lengths. This does not impair, in fine, the
compared with pacing at site C. Similarly, if there is no evaluation of CTI conduction. Indeed, considering a hypo-
lateromedial block, pacing at site A will lead to an earlier thetical rate-dependent isthmus-conduction velocity, a CTI
depolarization of site D compared with pacing at site B. The block will be preferentially observed with fast pacing, yet a
rationale for these assertions is based on anatomy and slower AF remains possible. Inducibility of AF will be less
conduction delay, the stimulus to local activation time being likely, however, with CTI blocks occurring during slow
shorter when the paced area is closest. There is still, however, pacing.
one limitation with the AF model using conduction delay The duration of the follow-up period, with an average of
criteria. In case of a slow lateromedial conduction when 10.4 months, precludes evaluation of AF recurrence. When
pacing at site A, if the time interval necessary to reach point complete bidirectional CTI block is achieved at the end of the
D through the CTI route precisely equals or exceeds the time ablation procedure, Schumacher et al11 recently showed that
interval necessary to reach point D by the opposite clockwise the recurrence rate curve is flat after a 4-month follow-up
route parallel to the tricuspid annulus, then the AD delay will period, which is consistent with the delay of recurrence
Chen et al Atrial Flutter Ablation 2513

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Cavotricuspid Isthmus Mapping to Assess Bidirectional Block During Common Atrial
Flutter Radiofrequency Ablation
Jian Chen, Christian de Chillou, Tarek Basiouny, Nicolas Sadoul, Jorge Da Silva Filho, Isabelle
Magnin-Poull, Marc Messier and Etienne Aliot

Circulation. 1999;100:2507-2513
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doi: 10.1161/01.CIR.100.25.2507
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